LDSS-3139 (3/79)
GENERAL INSTRUCTIONS:
DEPARTMENT OF HEALTH
OFFICE OF HEALTH SYSTEMS MANAGEMENT
HOME ASSESSMENT ABSTRACT
1.
REASON FOR PREPARATION
…
ADMISSION TO LTHHCP
…
…
…
INITIAL EVALUATION FOR HOME HEALTH AIDE
REASSESSMENT FROM _______________ TO ______________
…
LTHHCP
…
OTHER, SPECIFY ______________________________________
ABBREVIATIONS:
INITIAL EVALUATION FOR PERSONAL CARE
…
…
CHHA
THIS FORM MUST BE COMPLETED FOR ALL LONG TERM HOME
HEALTH CARE PROGRAM PATIENTS AND ALL MEDICAID PATIENTS
RECEIVING HOME HEALTH AIDE OR PERSONAL CARE SERVICES.
PORTIONS AS INDICATED MUST BE COMPLETED BY RESPECTIVE
PERSONNEL FOR THE ABOVE MENTIONED PURPOSES. FOR MORE
INFORMATION, SEE DETAILED INSTRUCTIONS.
PERSONAL CARE
2. PATIENT NAME
CHHA – CERTFIED HOME HEALTH AGENCY
LTHHCP – LONG TERM HOME HEALTH CARE PROGRAM
RN – REGISTERED NURSE
SSW – SOCIAL SERVICE WORKER
INSTRUCTION PAGE 1:
TO BE COMPLETED BY RN – PARTS 1, 2, 3
TO BE COMPLETED BY SSW – PARTS 1, 2, 3, 4, 5, 6
3.
CURRENT LOCATION/DIAGNOSIS OF PATIENT
HOSP.
… HRF
… HOME
SNF
… DCF
… OTHER
(SPECIFY)
…
…
RESIDENT ADDRESS
CITY
STATE
ZIP
ADDRESS WHERE PRESENTLY RESIDING
APT. NO.
NAME OF FACILITY/ORGANIZATION
TEL. NO.
STREET
TEL. NO.
CITY
DIRECTIONS TO CURRENT ADDRESS
STATE
DATE ADMITTED
SOCIAL SERVICES DISTRICT
FIELD OFFICE
ZIP
TEL NO.
PROJECTED DISCHARGE DATE
DIAGNOSIS
4. NEXT OF KIN/GUARDIAN
STREET
5.
NOTIFY IN EMERGENCY
NAME
CITY
STATE
RELATION
ZIP
CITY
TEL NO.
RELATION
STATE
ZIP
TEL NO.
PATIENT INFORMATION
6. DATE OF BIRTH _____________________________AGE __________
LANGUAGE(S) SPOKEN/UNDERSTANDS _______________________
SEX:
…
…
MALE
MARITAL STATUS:
PART B _____________________________________
…
MARRIED
…
…
SINGLE
… DIVORCED
…
WIDOWED
… UNKNOWN
SEPARATED
ONE FAMILY HOUSE
…
HOTEL
…
MULTI-FAMILY HOUSE
…
APT.
…
FURNISHED ROOM
…
BOARDING HOUSE
…
SENIOR CIT. HOUSING
…
SPOUSE
…
BLUE CROSS NO. __________________________________________
WORKMENS COMP. _________________________________________
VETERANS CLAIM NO. ______________________________________
ALONE
…
YES
…
NO
OTHER (SPECIFY) __________________________________________
SOURCE OF INCOME/OTHER BENEFITS
IF WALK-UP
(# FLIGHTS ___)
OTHER, SPECIFY ___________________
…
MEDICAID NO. _________________________________ … PENDING
VETERANS SPOUSE
…
LIVES WITH:
MEDICARE NO. PART A _____________________________________
FEMALE
LIVING ARRANGEMENTS:
…
SOCIAL SECURITY NO. ______________________________________
…
OTHER ____________
…
SOCIAL SECURITY
…
PUBLIC ASSIST.
…
VETERANS BENEFITS
…
PENSION
…
FOOD STAMPS
…
S.S.I.
…
OTHER
(SPECIFY) ________
AMOUNT OF AVAILABLE FUNDS AFTER PAYMENT OF RENT, TAXES
UTILITIES, ETC. _____________________________________________
(1)
LDSS-3139 (3/79)
7. To be completed by S S W
OTHERS IN HOME/HOUSEHOLD: Indicate days/hours that these persons will provide care to patient.
If none will assist explain in narrative.
NAME
Age
Relationship
Days/Hours at Home
Days/Hours will Assist
1.
2.
3.
4.
8.
To be completed by S S W
SIGNIFICANT OTHERS OUTSIDE OF HOME: Indicate days/hours when persons below will provide care to patient.
Name
Address
Age
Relationship
Days/Hours Assisting
1.
2.
3.
4.
5.
9.
To be completed by S S W
COMMUNITY SUPPORT: Indicate organization/persons serving patient at present or has provided a service in the past six (6) months.
Presently
Receiving
Organization
Type of Service
Contact Person
1.
2.
3.
4.
10. To be completed by S S W and R.N.
PATIENT TRAITS:
Yes
No
Appears self directed and/or independent
Seems to make appropriate decisions
Can recall med routine/recent events
Participates in planning/treatment program
Seems to handle crises well
Accepts diagnosis
Motivated to remain at home
(2)
?N/A
If you check No. ?N/A, describe
Tel No.
LDSS-3139 (3/79)
11. To be completed by S S W and R.N. as appropriate
FAMILY TRAITS:
Yes
No
?
a.
Is motivated to keep patient home
If no, because
b.
Is capable of providing care (physically & emotionally)
If no, because
c.
Will keep patient home if not involved with care
Because
d.
Will give care if support service given
How much
e.
Requires instruction to provide care
In what – who will give
12. To be completed by R.N.
Home/Place where care will be provided:
Yes
No
?
If problem, describe
Neighborhood secure/safe
Housing adequate in terms of:
Space
Convenient toilet facilities
Heating adequate and safe
Cooking facilities & refrigerator
Laundry facilities
Tub/shower/hot water
Elevator
Telephone accessible & usable
Is patient mobile in house
Leaky gas, poor wiring, unsafe floors,
steps, other (specify)
Any discernible hazards (please circle)
Construction adequate
Excess use of alcohol/drugs by patient/
caretaker; smokes carelessly.
Is patient’s safety threatened if alone?
Pets
ADDITIONAL ASSESSMENT FACTORS:
13. To be completed by R.N.
RECOVERY POTENTIAL ANTICIPATED
COMMENTS
Full recovery
…
Recovery with patient management residual
…
Limited recovery managed by others
…
Deterioration
…
(3)
LDSS-3139 (3/79)
14. To be completed by R.N. – S S W to complete “D” as appropriate
FOR THE PATIENT TO REMAIN AT HOME – SERVICES REQUIRED
WHO WILL PROVIDE
SERVICES REQUIRED
A.
YES
NO
TYPE/FREQ/DUR
AGENCY/FAMILY
AGENCY FREQUENCY
Bathing
Dressing
Toileting
Admin. Med.
Grooming
Spoon feeding
Exercise/activity/walking
Shopping (food/supplies)
Meal preparation
Diet Counseling
Light housekeeping
Personal laundry/household linens
Personal/financial errands
Other
B.
Nursing
Physical Therapy
Home Health Aide
Speech Pathology
Occupational Therapy
Personal Care
Homemaking
Housekeeping
Clinic/Physician
Other
1.
2.
C.
Ramps outside/inside
Grab bars/hallways/bathroom
Commode/special bed/wheelchair
Cane/walker/crutches
Self-help device, specify
Dressings/cath. equipment, etc.
Bed protector/diapers
Other
D.
2
Additional Services (Lab, O , medication)
Telephone reassurance
Diversion/friendly visitor
Medical social service/counseling
Legal/protective services
Financial management/conservatorship
Transportation arrangements
Transportation attendant
Home delivered meals
Structural modification
Other
15.
To be completed by S S W and R.N
DMS Predictor Score ____________________________________ Override necessary
…
Yes
…
No
Can patient’s health/safety needs be met through home care now?
…
Yes
…
No
If no, give specific reason why not
Institutional care required now?
…
Yes
…
No
If yes, give specific reason why.
…
Level of institutional care determined by your professional judgment:
Can the patient be considered at a later time for home care?
…
Yes
(4)
…
SNF
…
No
…
HRF
…
N/A
DCF
LDSS-3139 (3/79)
16. To be completed by S S W
SUMMARY OF SERVICE REQUIREMENTS
Indicate services required, schedule and charges (allowable charge in area)
Services
Provided by
Hrs./Days/Wk.
Date
Effective
Physician
Nursing
Home Health Aide
Physical Therapy
Speech Pathology
Resp. Therapy
Med. Soc. Work
Nutritional
Personal Care
Homemaking
Housekeeping
Other (Specify)
Medical Supplies/Medication
1.
2.
3.
Medical Equipment
1.
2.
3.
Home Delivered Meals
Transportation
Additional Services
1.
2.
SUBTOTAL
Structural Modification
Other (Specify)
1.
2.
SUBTOTAL
TOTAL COST
(5)
Est.
Dur.
Unit
Cost
Payment by
MC
MA
Self
Other
LDSS-3139 (3/79)
17. To be completed by S S W and R.N.
Person who will relieve in case of emergency
Name
Address
Telephone
Narrative: Use this space to describe aspects of the patients care not adequately covered above.
Assessment completed by:
R.N.
Agency
Date Completed
Telephone No.
Local DSS Staff
District
Date Completed
Telephone No.
Supervisor DSS
District
Date
Telephone No.
Authorization to provide services:
Local DSS Commissioner or Designee
Date
(6)
Relationship